Healthcare Provider Details

I. General information

NPI: 1720246531
Provider Name (Legal Business Name): MADISON FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1739 MICHIGAN RD
MADISON IN
47250-2721
US

IV. Provider business mailing address

1739 MICHIGAN RD
MADISON IN
47250-2721
US

V. Phone/Fax

Practice location:
  • Phone: 812-273-6744
  • Fax: 812-265-4025
Mailing address:
  • Phone: 812-273-6744
  • Fax: 812-265-4025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12010146A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3853
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8174
License Number StateIN

VIII. Authorized Official

Name: DR. JESSE WILLIAM DUQUETTE
Title or Position: OWNER
Credential: DDS
Phone: 812-273-6744